Mary Jones
30 Sept 2019 · Coroner Alison Mutch · Manchester (South)
A similar concern from this report was raised again 2 times later. See the linked reports.
The coroner's concerns
1. frail elderly patient transferred out of hours
“[the deceased] was a frail elderly lady who was moved from the MRI to Trafford General post-operatively for rehabilitation under the Trust structure. It was a planned transfer. However due to limited transport availability she arrived at Trafford General out of hours after waiting for transfer. As a result she was clerked in and risk assessed out of hours despite the recognised risks of moving frail elderly patients out of hours. The inquest was told that this is not uncommon as transfers such as th”
2. falls risk assessment delayed
“The falls risk assessment was completed outside the Trust target time primarily as a result of the late arrival”
3. poor quality nursing documentation
“The documentation within the nursing notes, particularly the fluid charts was poor quality, making it difficult to understand what had happened in relation to the hydration of Mrs [name redacted]”
4. loss of medical records due to IT merger
“The documentation issue was exacerbated by the Trust IT merger having resulted in the loss of a number of key documents. It was unclear how the Trust were managing the risks around lost medical records where the IT merger was at the root of the issue”
5. missing nutrition referral
“Despite her frailty there was no evidence available at the inquest of a referral to a dietician/nutritionist. There was to have been a referral to SALT in February but no trace could be found of the referral”
6. lack of clinical review of fluid charts
“There was no evidence of clear clinical review of the outcome of the fluid charts”
Linked reports
Identical hazardConfidence 0.90 · high
This report
“The documentation within the nursing notes, particularly the fluid charts was poor quality, making it difficult to understand what had happened in relation to the hydration of Mrs [name redacted]”
Later report
“During the course of the inquest the documentation relied on by the trust was lacking in detail and meant that it was difficult to understand her condition at key points or to understand the rationale for decisions.”
Closely relatedConfidence 0.90 · high
This report
“The documentation within the nursing notes, particularly the fluid charts was poor quality, making it difficult to understand what had happened in relation to the hydration of Mrs [name redacted]”
Later report
“The GMMH documentation was of a poor quality and did not capture key discussions/decisions including in relation to medication.”
Responses
No published response was found on judiciary.uk.